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Medical statements reflect amounts owed from insurer

I need help with a bill from Eye Institute of West Florida in Largo. Evidently it is not correctly billing our supplemental insurance companies, and I keep receiving bills. The Eye Institute should file first with Medicare, then Wassau Benefits and then Tricare. Instead, the statements show it is filing claims with General American, not Wassau.

I haven't had any trouble with other clinics or doctors, and my husband, who is a diabetic, goes to many.

It has been a year and the collectors will soon be after me.

_ Mabel Boyle

Kris Richards, administrator for the Eye Institute of West Florida in Largo, said that it is unusual for a patient to be covered under three insurance companies, as your husband is. Red flags are always raised at the tertiary company to ensure that the other two have paid first.

Your husband has been a patient at the Eye Institute for a long time, she said, and Medicare has been billed and has paid its share, less the deductible, for all but the most recent claims. For nine months, the Eye Institute was running on two practice management systems. The statements showing General American that you included with your letter were generated by the old system, which is no longer being used.

To clear up any confusion, she said the current balance on your husband's account is $1,260. Keep in mind that this includes charges from July 21, July 23 and Aug. 5, for which no insurance payments have yet been received. Both Medicare and Wassau have paid for all claims that have been filed. For dates of service in January, however, a total of $489.70 is still due from Tricare.

Richards said the Eye Institute has billed Tricare on four separate occasions: Feb. 5, May 27, June 24 and Aug. 16. Each time Tricare has denied the claim, stating that copies of Medicare and Wassau statements explaining benefits are required. Richards said these were submitted with the claims, the last time by certified mail, return receipt requested. Apparently the explanation of benefit statements are being separated from the claims once they reach Tricare. The Eye Institute's staff is in contact with Tricare to attempt to resolve this issue.

With regard to the statements you have continued to receive, Richards said that when an insurance company denies payment, the Eye Institute's practice management system is designed to notify patients through billing statements. This allows patients to act as their own advocates if there is a problem. It also helps to keep them informed of the institute's progress in resolving any outstanding issues.

Your fear about credit collectors is unfounded, she said. Collection agencies are rarely used by the Eye Institute, and it would never do so without written notification to patients that give them adequate time to respond.

She said she cannot promise that there will not be a balance due because the Eye Institute has not yet received an adequate response from Tricare. However, she said it will continue to pursue the issue with Tricare, and she has every expectation that Tricare will pay its share of the outstanding claims.

Your frustration about claims for medical service is not uncommon, although as Richards pointed out, most patients do not have three insurance carriers involved. If the Eye Institute is not able to resolve this problem with Tricare, let us know, and we will attempt to help. Right now our involvement could simply confuse the matter further.

Alternatively, as a Medicare recipient, you may also turn to SHINE (Serving Health Insurance Needs of Elders). This volunteer-based program helps patients and caregivers with Medicare and other health insurance issues. Call the toll-free Senior Helpline at 1-800-963-5337.

Action solves problems and gets answers for you. If you have a question, or your own attempts to resolve a consumer complaint have failed, write Times Action, P.O. Box 1121, St. Petersburg, FL 33731, e-mail actionsptimes.com, or call your Action number, (727) 893-8171, or, outside of Pinellas, toll-free 1-800-333-7505, ext. 8171, to leave a recorded request.

We will not be responsible for personal documents, so please send only photocopies. If your complaint concerns merchandise ordered by mail, we need copies of both sides of your canceled check.

We may require additional information or prefer to reply by mail; therefore, readers must provide a full mailing address, including ZIP code. Names of letter writers will not be omitted except in unusual circumstances. Letters may be edited for length and clarity.

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